PAIN ASSESSMENT AND MANAGEMENT POLICY
To provide a guideline for the assessment and management of pain specific to age, culture, and
Sentara Williamsburg Community Hospital
Sentara Williamsburg Geddy Outpatient Care Center
Sentara Williamsburg Ambulatory Surgery Center
Williamsburg Community Hospital recognizes that it is every person’s right to have his or her
pain appropriately and aggressively managed.
Recognizing that pain can occur from infancy to elderly and that people who are unconscious or
otherwise unable to speak for themselves can perceive it. Assessment tools include both
subjective and objective measures of pain.
The self-report of pain by a patient is considered sufficient evidence to establish pain as a
Pain management is a multidisciplinary process involving the patient, the family/significant
others, nurses, physicians, pharmacists and all members of the healthcare team as necessary.
The pain management’s plan for the patient will consider personal, cultural, spiritual and ethnic
Within Sentara Williamsburg Community Hospital the following treatment modalities are used
to assist patients with treatment of pain:
• Medications: NSAIDS, oral narcotics, injections, PCA pumps
• Implanted pain pumps or devices
• Non-traditional modalities: distraction techniques, repositioning, music therapy, hot and
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• Inpatient and outpatient pain consultation with anesthesiology/pain management
Assessment of Pain
To assure continuity of care throughout the organization, all pain assessments will provide a
systematic approach of data collection using the provided tools of documentation specific to the
age and condition of the patient. Prioritizing and planning of interventions to relieve pain shall
be performed in collaboration with the patient/family.
The RN or physician shall perform an initial assessment for acute pain and, if relevant, for
chronic pain, on all patients admitted to the emergency area, inpatient, or outpatient departments.
Pain will be assessed using one of the following pain scales:
• 0-10 scale B this is a subjective scale where the patient communicates the current
level of pain. Zero equals no pain and 10 equals the most severe pain the patient
can imagine. In order to use this scale, the patient must be alert, oriented, and
cognitively able to understand the rating scale.
• Happy face B Sad face B this is a subjective scale where the patient
communicated their level of pain by pointing to the picture that most accurately
describes his current level of pain. Happy face means no pain and sad face with
tears is the most severe pain the patient can imagine. To use this scale the patient
must be alert and oriented.
• FLACC scale B this is an objective measure that can be used for the patient who
is unable to communicate. (See Below). When using this scale it is important to
obtain a complete history from the infant, child or adult’s care giver(s). In
addition, a baseline of usual behavior can be obtained from records of this or
another facility. It is essential to differentiate behavioral expressions of pain from
otherwise normal behavior for the patient in a similar situation.
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Observation Value = 0 Value = 1 Value = 2
FACE No particular expression Occasional grimace or Frequent to constant
or smile frown, withdrawn, frown, clenched jaw, or
disinterested quivering chin
LEGS Normal position or Uneasy, restless, tense Kicking or legs drawn up
ACTIVITY Lying quietly, moves Squirming, tense, or Arched, rigid or jerking
easily shifting back and forth
CRY No crying (asleep or Moans, whimpers, or Cries steadily, screams,
awake) occasional complaint sobs, or frequent
CONSOLABILITY Content or relaxed Reassured by occasional Difficult to console or
touching, hugging, or comfort
Atalking to@, distractible
If the patient reports the presence of pain, a more detailed history of the acute and/or chronic
pain will be taken and may include the following data:
• Location of pain. If more than one location they are assessed separately.
• Type, quality, and patterns of radiation (if applicable)
• Alleviating and aggravating factors
• Intensity Rating (visual analog or FLACC scale)
• Patient’s acceptable rating of pain and pain management history
• Current medications for pain and what works best
• Alternative methods of pain control used
• Vital signs
• Patient’s emotional and behavioral expressions of pain
• Level of influence of pain on ADLs
For the patient undergoing moderate sedation or anesthesia, pain assessment and intervention
should begin when the patient shows behavioral expressions or verbal expressions of pain.
Reassessment of Pain
If the patient is being cared for over the period of several hours and she/he has stated the
presence of pain, that pain will be reassessed as follows:
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A. A comprehensive acute assessment is completed and documented with every routine
B. A numerical intensity rating of pain is assessed with every set of vital signs, within one
hour of an intervention for pain, every four hours while awake, and if the patient
spontaneously reports pain.
C. Interventions must be documented when the intensity rating is >4 or greater than the
patient’s stated acceptable level of pain. Pain intensity rating is reassessed and
documented within 1 hour after each intervention until the intensity rating is 4 or less or
the patient’s stated level of acceptable pain.
D. Changes from the initial comprehensive assessment of pain should be documented as
E. Pain intensity rating will be reassessed with appropriate interventions 30 minutes prior to
physical therapy or activity to optimize performance.
F. Pain will be reassessed when a patient experiences painful procedures and interventions
documented with reassessment within 1 hour of each intervention.
G. Pain must be reassessed and documented prior to transfer from nurse to nurse, department
to department, or facility to facility, and immediately prior to discharge. A written or
verbal report on pain will be communicated upon transfer of care.
H. One hour following any narcotic given for pain relief even if given as a scheduled
Patient and family education about pain is provided to all at-risk clients.
This teaching includes but is not limited to the following:
A. The patient’s right to controlled pain
B. His/her responsibility to give an accurate subjective assessment and report pain on
a numerical or happy face scale.
C. To discuss probable physiological causes of pain that may be specific to the
D. To discuss barriers to good pain control.
E. To address patient fears.
F. To discuss alternative methods of pain management.
G. To report pain as soon as it starts before it gets severe because it is much easier to
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H. How to take the prescribed medication to get the optimal effect.
I. Potential limitations and side effects of pain treatments.
Patient teaching about pain occurs in the following ways:
• Pain video on Get Well Network
• Pain booklet
• Individual teaching sessions between the clinicians and patient/family
• PCA booklet
Planning for Pain Management after Discharge:
Assessment and planning for the need for pain control after discharge should be a collaborative
effort between the patient/family, the nurse, the physician and other members of the
interdisciplinary team as relevant. Instructions to the patient will be given on the Discharge
Age Specific Considerations:
The approach of Williamsburg Community Hospital to infant pain assessment is made on
the basis of the following assumptions or beliefs:
• Infants are capable of feeling pain. Infants have the anatomic and functional
requirements to process pain from mid to late gestation.
• Infants are as sensitive to pain as older children and adults. Term neonates have the
same sensitivity to pain as older infants and children. Pre-term neonates may have a
greater sensitivity to pain.
• Infants are capable of expressing pain. Although infants cannot verbalize pain, they
respond with behavioral cues and physiologic indicators that can be observed by the
family and health care professionals.
• Pain requires no prior experience; it need not be learned from earlier experience. Pain is
present from the first insult.
• Pain can be accurately assessed in infants. Assessment of behavioral cues (facial
expressions, cry, body movements, etc.) And physiologic indicators (increased vital
signs, change in oxygen requirements, etc.).
• Infants are capable of remembering pain. Early exposure to painful stimuli may have an
effect on the infant’s future responses to pain.
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• Analgesics and anesthetics can be safely given to infants and neonates. Infants older
than one month of age can metabolize drugs in the same manner as older infants and
children. Careful selection of the agent, dose, route and time, monitoring for desired
effects, drug titration and weaning can minimize the adverse effects of medication used
in the pain management of neonates.
The health care professional must consider the developmental stage of the infant and use
strategies to minimize pain opportunities in the care of the infant.
Care givers need to be educated about how much pain their infant will anticipate during and after
major and minor procedures and what interventions will be implemented to prevent or minimize
their infant’s pain.
Ages 0 - 17
The health care professional must consider the age of the pediatric patient and the current
stressors of the situation they are under when making the decision of which pain scale to utilize.
If the pediatric patient is able to clearly communicate, the adult scale may be utilized. Care must
be made with this group to ensure that the patient’s subjective measure of pain is not lower than
the practitioner’s objective assessment.
Patient education must include the parents or guardians. They need to be educated about how
much pain their child will anticipate during and after major and minor procedures and what
interventions will be implemented to prevent or minimize their child’s pain.
Efforts are made to take pediatric patients to a treatment room for any painful procedures. This
allows them to continue to feel safe in their own patient room.
Many elderly individuals consider pain to be a normal part of aging.
Many are reluctant to report pain due to ageist attitudes (such as Aold people complain about
pain a lot,@ Athey have difficulty using a PCA,@ Athey are unreliable pain reporters.
Many fear being perceived as bothersome, a hypochondriac or an addict.
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Pain is often under treated and under reported in this population
Many geriatric persons are numerous medications and need close monitoring for potential
drug interactions with pain medication.
Performance Improvement Initiatives:
The Quality Board will monitor compliance with this policy on a quarterly basis. The Pain
Improvement Team will take the following items into consideration as they monitor
• chart audits for compliance with documentation
• patient satisfaction surveys
• education offered during quarter on pain topics
• random inpatient interviews to assess patient satisfaction/education re: pain management
Vice President, Patient Care Services Date
Pain Team: 12/05
Patient Care Interdisciplinary Council: 12/05
Medical Executive Committee: 8/02; 1/06
Board of Directors: 8/02